Catastrophic health expenditure in sub-Saharan Africa: systematic review and meta-analysis.

Objective: To estimate the incidence of, and trends in, catastrophic health expenditure in sub-Saharan Africa. Methods: We systematically reviewed the scientific and grey literature to identify population-based studies on catastrophic health expenditure in sub-Saharan Africa published between 2000 and 2021. We performed a meta-analysis using two definitions of catastrophic health expenditure: 10% of total household expenditure and 40% of household non-food expenditure. The results of individual studies were pooled by pairwise meta-analysis using the random-effects model. Findings: We identified 111 publications covering a total of 1 040 620 households across 31 sub-Saharan African countries. Overall, the pooled annual incidence of catastrophic health expenditure was 16.5% (95% confidence interval, CI: 12.9-20.4; 50 datapoints; 462 151 households; I 2 = 99.9%) for a threshold of 10% of total household expenditure and 8.7% (95% CI: 7.2-10.3; 84 datapoints; 795 355 households; I 2 = 99.8%) for a threshold of 40% of household non-food expenditure. Countries in central and southern sub-Saharan Africa had the highest and lowest incidence, respectively. A trend analysis found that, after initially declining in the 2000s, the incidence of catastrophic health expenditure in sub-Saharan Africa increased between 2010 and 2020. The incidence among people affected by specific diseases, such as noncommunicable diseases, HIV/AIDS and tuberculosis, was generally higher. Conclusion: Although data on catastrophic health expenditure for some countries were sparse, the data available suggest that a non-negligible share of households in sub-Saharan Africa experienced catastrophic expenditure when accessing health-care services. Stronger financial protection measures are needed.

Acceptability of mobile-phone reminders for routine childhood vaccination appointments in Nigeria - a systematic review and meta-analysis.

BACKGROUND: Mobile-phone reminders have gained traction among policymakers as a way to improve childhood vaccination coverage and timeliness. However, there is limited evidence on the acceptability of mobile-phone reminders among patients and caregivers. This systematic review and meta-analysis aimed to evaluate the ownership of mobile-phone device and the willingness to receive mobile-phone reminders among mothers/caregivers utilizing routine childhood immunization services in Nigeria. METHOD: MEDLINE, Scopus, CINAHL, CNKI, AJOL (African Journal Online), and Web of Science were systematically searched for studies on the acceptability of mobile-phone reminders for routine immunization appointments among mothers/caregivers in Nigeria. Studies were assessed for methodological quality using the Newcastle Ottawa Scale and JBI critical appraisal checklists. Meta-analysis was conducted using random-effects model to generate pooled estimates (proportion) of mothers who owned at least one mobile phone and proportion of mothers willing to receive mobile-phone reminders. RESULTS: Sixteen studies (13 cross-sectional and three interventional) involving a total of 9923 mothers across 15 states and the Federal Capital Territory Abuja met inclusion criteria. Pooled estimates showed that the proportion of mothers who owned at least one mobile phone was 96.4% (95% CI = 94.1-98.2%; I2 = 96.3%) while the proportion of mothers willing to receive mobile-phone reminders was 86.0% (95% CI = 79.8-91.3%, I2 = 98.4%). Most mothers preferred to receive text message reminders at least 24 h before the routine immunization appointment day, and in the morning hours. Approximately 52.8% of the mothers preferred to receive reminders in English, the country's official language. CONCLUSION: Current evidence suggests a high acceptability for mobile-phone reminder interventions to improve routine childhood immunization coverage and timeliness. Further studies, however, are needed to better understand unique regional preferences and assess the operational costs, long-term effects, and risks of this intervention. SYSTEMATIC REVIEW PROTOCOL REGISTRATION: PROSPERO CRD42021234183.

A community-based assessment of the perception and involvement of male partners in maternity care in Benin-City, Nigeria.

Male involvement in maternal health promotion is paramount to safe motherhood. This study evaluates the perception and participation of male partners in maternity care (MC). A cross-sectional study involving 372 participants was conducted through qualitative (interviews and focus group discussion) and quantitative research methods which assessed knowledge, attitude and perception, between 1 December 2017 and 21 January 2018. The data were analysed with IBM SPSS version 25.0 using descriptive and inferential statistics. The mean age of the participants was 35.9 ± 11.5 years. Four-fifths (80.4%) had a positive attitude towards MC but only 27.2% was actively involved, due to socio-cultural reasons. Knowledge regarding MC was associated with age (p = .023), employment (p = .039) and education (p = .002) - higher among younger-aged professionals with a higher education. Male partners had a positive attitude towards MC but were poorly involved, due to socio-cultural factors. Community health workers and stakeholders should step up community health education with engagement of men to promote their involvement.Impact statementWhat is already known on this subject? The role of men in maternity care (MC) is well defined and found to improve health outcomes in high income countries. However, their level of participation in a low income country, such as Nigeria, is far below expectation.What do the results of this study add? The result of this work has provided scarce community-based local data on male partners' involvement in MC. This study showed that majority of males demonstrated a positive attitude but were poorly involved, due to socio-cultural reasons. It also shown that those with a younger age, professionals and those with a higher education were more knowledgeable about MC. This suggests the need for health workers and key players to step up community health education and engagement of men to promote active involvement in women's health matters.What are the implications of these findings for clinical practice and/or further research? Stakeholders in low resource-settings like Nigeria could introduce interventions to scaling up health education, create the enabling hospital environment to accommodate male partners, actively engage, support and motivate them to be involved in MC. Further research will be required to assess the impact of such interventions and how to sustain potential benefits.

Perinatal outcomes of babies delivered by second-stage Caesarean section versus vacuum extraction in a resource-poor setting, Nigeria - a retrospective analysis.

BACKGROUND: To evaluate the perinatal status of neonates delivered by assisted vaginal delivery (AVD) versus second-stage caesarean birth (CS). METHODS: A 5-year retrospective study was conducted in a tertiary hospital. Data was analyzed with IBM SPSS® version 25.0 statistical software using descriptive/inferential statistics. RESULTS: A total of 559 births met the inclusion criteria; AVD (211; 37.7%) and second-stage CS (348; 62.3%). Over 80% of the women were aged 20-34 years: 185 (87.7%) for the AVD group, and 301 (86.5%) for the second-stage CS group. More than half of the women were parous: 106 (50.2%) for the AVD group, and 184 (52.9%) for the second-stage CS group. The commonest indication for intervention in both groups is delayed second stage: 178 (84.4%) in the AVD group, and 239 (68.9%) in the second-stage CS group. There was a statistically significant difference in decision to delivery interval (DDI) between both groups: 197 (93.4%) women in the AVD group had DDI of less than 30 min and 21 women (6.0%) in the CS group had a DDI of less than 30 min (p <  0.001). During the DDI, there were 3 (1.4%) intra-uterine foetal deaths (IUFD) in the AVD and 19 (5.5%) in the CS group (p = 0.023). After adjusting for co-variates, there were statistically significant differences between the AVD and CS groups in the foetal death during DDI (p = 0.029) and perinatal deaths (p = 0.040); but no statistically significant differences in severe perinatal outcomes (p = 0.811), APGAR scores at 5th minutes (p = 0.355), and admission into the NICU (p = 0.946). After adjusting for co-variates, use of AVD was significantly associated with the level of experience of the care provider, with resident (junior) doctors less likely to opt for AVD than CS (aOR = 0.45, 95% CI: 0.29-0.70). CONCLUSION: Second-stage CS when compared with AVD was not associated with improved perinatal outcomes. AVD is a practical option for reducing the rising Caesarean delivery rates without compromising the clinical status of the newborn.

Perception and attitudinal factors contributing to periodic deworming of preschool children in an urban slum, Nigeria.

BACKGROUND: Over 20 million preschool-age children (PSAC) in Nigeria require periodic chemotherapy (PC) for soil-transmitted helminth (STH) infections. Persistently low coverage for this age group threatens the World Health Organization (WHO) 2030 target for eliminating STH infections. Current strategies for targeting PSAC have been largely ineffective. Hence, PSAC are mostly dewormed by their parents/caregivers. However, little is known of the perception and attitude of parents/caregivers of PSAC to deworming in this setting. METHODS: A mixed methods design, combining a community-based interviewer-administered questionnaire-survey (n = 433) and focus group discussions (FGD) (n = 43) was used to assess the perceptions and attitudes of mothers to periodic deworming of preschool children aged 2-5 years in Abakpa-Nike, Enugu, Nigeria. RESULTS: Coverage of periodic deworming in PSAC is 42% (95% CI: 37.3-46.8%). There is significant difference in the specific knowledge of transmission of STH (AOR = 0.62, 95% CI: 0.48-0.81, p = 0.000), complication of STH infections (AOR = 0.77, 95% CI: 0.61-0.98, p = 0.034), accurate knowledge of deworming frequency (AOR = 0.41, 95% CI: 0.18-0.90, p = 0.026), and knowledge of PC drug, mebendazole (AOR = 0.28, 95% CI: 0.09-0.90, p = 0.031), and pyrantel (AOR = 8.03, 95% CI: 2.22-29.03, p = 0.001) between mothers who periodically deworm their PSAC and those who do not. There is no significant difference in specific knowledge of the symptoms of STH infections (AOR = 0.76, 95% CI: 0.57-1.02, p = 0.069) and PC drug, Albendazole (AOR = 1.00, 95% CI: 0.46-2.11, p = 0.972). FGD revealed misconceptions that are rooted in stark ignorance of the disease. Overall attitude to deworming is positive and favourable. CONCLUSIONS: Poor coverage of periodic deworming for STH infections in PSAC in this setting are primarily driven by poor specific knowledge of the risks and burden of the infection. Focused health education on the burden and transmission of STH infections could complement existing strategies to improve periodic deworming of PSAC in this setting.

La Sota vaccination may not protect against virus shedding and the lesions of velogenic Newcastle disease in commercial turkeys.

The aim of this project is to study the clinical signs and lesion of velogenic Newcastle disease (vND) in commercial turkeys, and also to find out if La Sota vaccination offered protection against these signs and lesions. The cockerels were included as positive controls. One hundred and twenty turkey poults and cockerels were divided into eight groups as follows: unvaccinated unchallenged turkeys (UUT), unvaccinated challenged turkeys (UCT), vaccinated unchallenged turkeys (VUT), vaccinated challenged turkeys (VCT), and along the same lines, the cockerel groups were UUC, UCC, VUC and vaccinated challenged cockerels (VCC). Vaccination was at 3 weeks of age while challenge was at 6 weeks of age. The unvaccinated turkeys and cockerels (UCT and UCC) showed different degrees of depression, diarrhoea and later paralysis at challenge. Total mortality was 100% in cockerels within 6 days, but 60% in turkeys. Similar but milder clinical signs were found in the VCC with a total mortality of 13.3%. The VCT showed mild drop in feed and water consumption, and no mortality. All the challenged groups had significant (p < 0.05) loss of weight when compared with their controls. Necropsy showed that while the UCC had severe proventricular haemorrhages, intestinal and caecal tonsil ulcers, the UCT had no digestive tract lesion. There was severe atrophy of the lymphoid organs in all the challenged groups. Histopathological sections of the bursa, spleen and thymus in all the challenged groups with special emphasis on the vaccinated and unvaccinated turkeys with mortalities of 0 and 60%, respectively, had very severe necrosis and depletion of the lymphoid tissue. Virus was isolated from the cloacal swabs. The haemagglutination inhibition antibodies were significantly higher (p < 0.05) in the challenged groups than the unchallenged. The above observations in the intestinal tracts of UCT are of diagnostic significance while the gross and microscopic lesions in the UCT and VCT show that La Sota vaccination may not protect turkeys against the destruction of the lymphoid organs by vND as earlier reported in chickens. This may lead to immunosuppression and production problems in areas where vND is enzootic.

Evaluating health systems' efficiency towards universal health coverage: A data envelopment analysis.

To estimate the technical efficiency of health systems toward achieving universal health coverage (UHC) in 191 countries. We applied an output-oriented data envelopment analysis approach to estimate the technical efficiency of the health systems, including the UHC index (a summary measure that captures both service coverage and financial protection) as the output variable and per capita health expenditure, doctors, nurses, and hospital bed density as input variables. We used a Tobit simple-censored regression with bootstrap analysis to observe the socioeconomic and environmental factors associated with efficiency estimates. The global UHC index improved from the 2019 estimates, ranged from 48.4 (Somalia) to 94.8 (Canada), with a mean of 76.9 (std. dev.: ±12.0). Approximately 78.5% (150 of 191) of the studied countries were inefficient (ϕ < 1.0) with respect to using health system resources toward achieving UHC. By improving health system efficiency, low-income, lower-middle-income, upper-middle-income, and high-income countries can improve their UHC indices by 4.6%, 5.5%, 6.8%, and 4.1%, respectively, by using their current resource levels. The percentage of health expenditure spent on primary health care (PHC), governance quality, and the passage of UHC legislation significantly influenced efficiency estimates. Our findings suggests health systems inefficiency toward achieving UHC persists across countries, regardless of their income classifications and WHO regions, as well as indicating that using current level of resources, most countries could boost their progress toward UHC by improving their health system efficiency by increasing investments in PHC, improving health system governance, and where applicable, enacting/implementing UHC legislation.

Impact of community-based health insurance in low- and middle-income countries: A systematic review and meta-analysis.

BACKGROUND: To systematically evaluate the empirical evidence on the impact of community-based health insurance (CBHI) on healthcare utilization and financial risk protection in low- and middle-income countries (LMIC). METHODS: We searched PubMed, CINAHL, Cochrane CENTRAL, CNKI, PsycINFO, Scopus, WHO Global Index Medicus, and Web of Science including grey literature, Google Scholar®, and citation tracking for randomized controlled trials (RCTs), non-RCTs, and quasi-experimental studies that evaluated the impact of CBHI schemes on healthcare utilization and financial risk protection in LMICs. We assessed the risk of bias using Cochrane's Risk of Bias 2.0 and Risk of Bias in Non-randomized Studies of Interventions tools for RCTs and quasi/non-RCTs, respectively. We also performed a narrative synthesis of all included studies and meta-analyses of comparable studies using random-effects models. We pre-registered our study protocol on PROSPERO: CRD42022362796. RESULTS: We identified 61 articles: 49 peer-reviewed publications, 10 working papers, 1 preprint, and 1 graduate dissertation covering a total of 221,568 households (1,012,542 persons) across 20 LMICs. Overall, CBHI schemes in LMICs substantially improved healthcare utilization, especially outpatient services, and improved financial risk protection in 24 out of 43 studies. Pooled estimates showed that insured households had higher odds of healthcare utilization (AOR = 1.60, 95% CI: 1.04-2.47), use of outpatient health services (AOR = 1.58, 95% CI: 1.22-2.05), and health facility delivery (AOR = 2.21, 95% CI: 1.61-3.02), but insignificant increase in inpatient hospitalization (AOR = 1.53, 95% CI: 0.74-3.14). The insured households had lower out-of-pocket health expenditure (AOR = 0.94, 95% CI: 0.92-0.97), lower incidence of catastrophic health expenditure at 10% total household expenditure (AOR = 0.69, 95% CI: 0.54-0.88), and 40% non-food expenditure (AOR = 0.72, 95% CI: 0.54-0.96). The main limitations of our study are the limited data available for meta-analyses and high heterogeneity persisted in subgroup and sensitivity analyses. CONCLUSIONS: Our study shows that CBHI generally improves healthcare utilization but inconsistently delivers financial protection from health expenditure shocks. With pragmatic context-specific policies and operational modifications, CBHI could be a promising mechanism for achieving universal health coverage (UHC) in LMICs.

Validity of maternal recall for estimating childhood vaccination coverage - Evidence from Nigeria.

BACKGROUND: Vaccination coverage surveys in low- and middle-income countries typically estimate vaccination coverage using data from vaccination cards, parental recall, or a combination of the two. However, these surveys are often complicated by the pervasive absence of vaccination cards, forcing researchers to rely on parental recall. We assessed the validity of mothers' recall against home-based vaccination cards using data from a community-based household survey in Nigeria. METHODS: A cross-sectional survey of 1,254 mothers of children aged 12-23 months was performed in Enugu State, Nigeria in July 2020. Data on vaccination status for BCG, OPV, DPT, Measles, Yellow fever, and Vitamin A supplement were collected using two data sources: home-based vaccination cards and mothers' recall. We evaluated the level of agreement between the two data sources; estimated the sensitivity and specificity of mothers' recalls; and computed multivariable regression models to identify socio-demographic factors associated with mothers' recall bias. RESULTS: Out of 1,254 mothers interviewed, 578 (46.1%) mothers with vaccination cards were included in this analysis. Vaccination coverage levels were generally similar across data sources, though recall-based data generally underestimated the coverage. The level of agreement between the two data sources was high (≥91.0% for all vaccine types) with recall bias due to under-reporting generally higher than recall bias due to over-reporting. The sensitivity of parental recalls was high for all vaccine types, while the specificity was low across vaccine types. Across all vaccines, mothers recall bias was significantly associated with the rural residence and not receiving postnatal care. CONCLUSION: In the absence of vaccination cards, mothers' recall of their children' vaccination status for BCG, OPV, DPT, Measles, Yellow fever and Vitamin A is a valid instrument for estimating childhood vaccination coverage in this setting in Nigeria. However, additional research is needed to confirm these findings at higher sub-national and national levels.

Factors associated with catastrophic health expenditure in sub-Saharan Africa: A systematic review.

OBJECTIVE: A non-negligible proportion of sub-Saharan African (SSA) households experience catastrophic costs accessing healthcare. This study aimed to systematically review the existing evidence to identify factors associated with catastrophic health expenditure (CHE) incidence in the region. METHODS: We searched PubMed, CINAHL, Scopus, CNKI, Africa Journal Online, SciELO, PsycINFO, and Web of Science, and supplemented these with search of grey literature, pre-publication server deposits, Google Scholar®, and citation tracking of included studies. We assessed methodological quality of included studies using the Appraisal tool for Cross-Sectional Studies for quantitative studies and the Critical Appraisal Skills Programme checklist for qualitative studies; and synthesized study findings according to the guidelines of the Economic and Social Research Council. RESULTS: We identified 82 quantitative, 3 qualitative, and 4 mixed-methods studies involving 3,112,322 individuals in 650,297 households in 29 SSA countries. Overall, we identified 29 population-level and 38 disease-specific factors associated with CHE incidence in the region. Significant population-level CHE-associated factors were rural residence, poor socioeconomic status, absent health insurance, large household size, unemployed household head, advanced age (elderly), hospitalization, chronic illness, utilization of specialist healthcare, and utilization of private healthcare providers. Significant distinct disease-specific factors were disability in a household member for NCDs; severe malaria, blood transfusion, neonatal intensive care, and distant facilities for maternal and child health services; emergency surgery for surgery/trauma patients; and low CD4-count, HIV and TB co-infection, and extra-pulmonary TB for HIV/TB patients. CONCLUSIONS: Multiple household and health system level factors need to be addressed to improve financial risk protection and healthcare access and utilization in SSA. PROTOCOL REGISTRATION: PROSPERO CRD42021274830.

Interpregnancy interval after a miscarriage and obstetric outcomes in the subsequent pregnancy in a low-income setting, Nigeria: A cohort study.

Objectives: The aim of this study was to determine and compare the occurrence of adverse pregnancy outcomes in a cohort of pregnant women with interpregnancy interval of < and ⩾6 months (short and normal interpregnancy interval, respectively) following a spontaneous miscarriage in their last pregnancies. Methods: This was a cohort study that involved pregnant women with a spontaneous pregnancy loss in their last pregnancies. They were recruited at a gestational age of 13-15 weeks and followed up to determine the obstetric and foetal outcomes of their pregnancies at four tertiary hospitals in Nigeria from July 2018 to September 2019. Data collected were analysed using SPSS version 26.0. A Chi-square and multivariate logistic regression analysis were done, and a p-value of less than 0.05 was assumed to be statistically significant. Results: A total of 705 participants were studied, out of which 448 (63.5%) and 257 (36.5%) of the participants had short and normal interpregnancy interval after a spontaneous miscarriage. Over 80% of the participants had first-trimester pregnancy losses and were managed with manual vacuum aspiration in 73.3% of the cases. The majority, 87.5% for the normal interpregnancy interval cohort and 86.4% for the short interpregnancy interval cohort, had live births, while 8.5% and 10.1% of the women in the normal and short interpregnancy interval cohorts, respectively, had repeat miscarriages. There was no statistical difference in the occurrence of live births and repeat miscarriages between both cohorts (p > 0.05). There was no increased risk of occurrence of adverse foetomaternal outcomes in both groups (p > 0.05). Multivariate logistic regression analysis showed that there was no statistical difference in the occurrence adverse foetomaternal outcomes between the studied cohorts (p > 0.05). Conclusion: There was no significant difference in the occurrence of adverse maternal and foetal outcomes in the cohorts of mothers with short and normal interpregnancy interval following miscarriages in their last previous pregnancies.

Short message service (SMS) reminders for childhood immunisation in low-income and middle-income countries: a systematic review and meta-analysis.

INTRODUCTION: Childhood vaccine delivery services in the low- and middle-income countries (LMIC) are struggling to reach every child with lifesaving vaccines. Short message service (SMS) reminders have demonstrated positive impact on a number of attrition-prone healthcare delivery services. We aimed to evaluate the effectiveness of SMS reminders in improving immunisation coverage and timeliness in LMICs. METHODS: PubMed, Embase, Scopus, Cochrane CENTRAL, CINAHL, CNKI, PsycINFO and Web of Science including grey literatures and Google Scholar were systematically searched for randomised controlled trials (RCTs) and non-RCTs that evaluated the effect of SMS reminders on childhood immunisation and timeliness in LMICs. Risk of bias was assessed using the Cochrane Risk of Bias 2.0 assessment tool for RCTs and Cochrane Risk of Bias in Non-randomised Studies of Interventions tool for non-RCTs. Meta-analysis was conducted using random-effects models to generate pooled estimates of risk ratio (RR). RESULTS: 18 studies, 13 RCTs and 5 non-RCTs involving 32 712 infants (17 135 in intervention groups and 15 577 in control groups) from 11 LMICs met inclusion criteria. Pooled estimates showed that SMS reminders significantly improved childhood immunisation coverage (RR=1.16; 95% CI: 1.10 to 1.21; I2=90.4%). Meta-analysis of 12 included studies involving 25 257 infants showed that SMS reminders significantly improved timely receipt of childhood vaccines (RR=1.21; 95% CI: 1.12 to 1.30; I2=87.3%). Subgroup analysis showed that SMS reminders are significantly more effective in raising childhood immunisation coverage in lower middle-income and low-income countries than in upper middle-income countries (p<0.001) and sending more than two SMS reminders significantly improves timely receipt of childhood vaccines than one or two SMS reminders (p=0.040). CONCLUSION: Current evidence from LMICs, although with significant heterogeneity, suggests that SMS reminders can contribute to achieving high and timely childhood immunisation coverage. PROSPERO REGISTRATION NUMBER: CRD42021225843.

Using i-tree canopy vegetation cover subtype classification to predict peri-domestic tick presence.

While extant literature has generally indicated significant associations between vegetation cover and tick activity, no study has demonstrated the relative association between peri-domestic area vegetation cover subtypes and tick presence. In this study, we seek to determine whether neighborhood wood index and residential tick control practices confound or modify the effect of peri-domestic vegetation cover subtypes on tick presence. We conducted an ecological inventory of vegetation cover distribution using i-Tree Canopy on 210 private residential/peri-domestic properties in Indiana, USA. Results were paired with field obtained tick presence/absence data for each property together with online survey data provided by primary occupant of the property. Amblyomma americanum was the predominant tick species in peri-domestic areas. Higher proportion of vegetation cover in the peri-domestic area was significantly associated with tick presence. Of the four vegetation cover subtypes, (grass, shrubs, understory, and canopy), canopy was the most prevalent vegetation in peri-domestic areas of Indiana, USA. It was also the most significant predictor of tick presence. Among residential tick control processes, frequent leaf litter removal was significantly associated with reduced likelihood of peri-domestic tick presence. Neighborhood Wood Index (NWI) confounded the relationship between canopy and peri-domestic tick presence, while leaf-litter removal confounded the effect of understory vegetation subtype on peri-domestic tick presence. Compared to peri-domestic areas in neighborhoods with sparse NWI, those in neighborhoods with heavy/dense NWI had a 3.5x odd of peri-domestic tick presence (AOR = 3.46; 95 % CI: 1.23-9.65). Compared to peri-domestic areas in the central region, those in the southern region of Indiana were 8.7x more likely to have peri-domestic tick presence. Canopy as a vegetation cover subtype and frequent leaf litter removal represent particularly key peri-domestic variables that have significant implications for peri-domestic tick presence. Beyond parcel-scale landscape features, neighborhood wood index also plays an important role in peri-domestic tick presence. Additionally, i-Tree Canopy represents a promising methodological tool for identifying landscape features that predict tick presence.

Preventing tick-bites among children in Indiana, USA: An analysis of factors associated with parental protective behaviors.

Despite evidence to the effect that there is low parental adoption of tick-bite personal protective behavior (PPB) for their children - a population at high risk for tick exposure, very limited information is available on factors associated with parental adoption of PPB. The objective of this study was to identify the most significant factors associated with parental adoption of tick-bite PPB on behalf of a child or children at risk of tick encounters. A cross-section of parents in Indiana, USA whose child had spent time outdoors in tick habitat during the summer were recruited from representative online panels maintained by Qualtrics. Binary logistic regression was used to model determinants of five tick-bite PPBs. Our results revealed that the application of tick repellent (89 %, n = 718) followed by conducting a tick check of the child's body soon after returning from the outdoors (84 %, n = 676) were the PPBs most frequently adopted by parents. Conversely, tucking one's shirt into pants and pants into socks was the least frequently adopted PPB (48 %, n = 386). Compared to other factors evaluated in logistic regression models, parents who reported implementing one or more residential tick control practices were significantly more likely to adopt nearly all five tick-bite PPBs for their children. Additionally, parents who were more worried about their health due to ticks and reported being more likely to avoid the outdoors because of ticks were more likely to adopt at least three PPBs on behalf of their children. To ensure children can most safely engage in outdoor activity, identifying the factors associated with parental adoption of tick-bite preventive behaviors represents an important mechanism in the prevention of tick-borne diseases.

Efficacy and safety of chloroquine and hydroxychloroquine for treatment of COVID-19 patients-a systematic review and meta-analysis of randomized controlled trials.

The coronavirus disease 19 (COVID-19) pandemic has caused significant morbidity and mortality worldwide and an effective treatment is needed. Chloroquine (CQ) and hydroxychloroquine (HCQ) have shown in vitro antiviral activity against SARS-CoV-2 which causes the disease, but the evidence from in vivo studies so far has been inconclusive. OBJECTIVE: To evaluate the efficacy and safety of CQ and HCQ in the treatment of COVID-19. DATA SOURCES: We systematically searched the PubMed, Embase, MEDLINE, Cochrane CENTRAL, CINAHL, Scopus, Joanna Briggs Institute Database, ClinicalTrials.gov, and Chinese Clinical Trial Registry (ChiCTR) for all articles published between 01 January 2020 to 15 September 2020 on CQ/HCQ and COVID-19 using a predefined search protocol; without any language restrictions. A search of grey literature repositories (New York Academy of Medicine Grey Literature and Open Grey), and pre-publication server deposits (medRxIV and bioRxIV) was also performed. STUDY SELECTION: Randomized clinical trials (RCT) which compared CQ/HCQ to standard supportive therapy in treating COVID-19 were included. DATA EXTRACTION AND SYNTHESIS: Data were extracted from original publications by four independent reviewers. Risk of bias was assessed using the Cochrane Collaboration's assessment tool. Data were meta-analyzed using a random-effect models. Results are reported according to PRISMA guidelines. Main Outcome(s) and Measure(s): The primary prespecified efficacy outcome was all-cause mortality. The primary safety outcome was any adverse effect attributed to use of CQ/HCQ. RESULTS: Eight RCTs were included and pooled in the mortality meta-analysis (6,592 unique participants; mean age = 59.4 years; 42% women). CQ/HCQ did not show any mortality benefit when compared to standard supportive therapy (Pooled Relative Risk [RR] 1.07; 95% CI = 0.97-1.18; I2 statistic = 0.00%). Sensitivity and sub-group analyses showed similar findings. Any adverse event was significantly higher in patients randomized to CQ/HCQ (RR = 2.51; 95% CI = 1.53-4.12; n = 1,818 patients), but the risk of developing severe adverse event was not statistically significant (RR = 0.99, 95% CI = 0.53-1.86; n = 6,456 patients). CONCLUSIONS AND RELEVANCE: Evidence from currently published RCTs do not demonstrate any added benefit for the use of CQ or HCQ in the treatment of COVID-19 patients.

Factors associated with incomplete immunisation in children aged 12-23 months at subnational level, Nigeria: a cross-sectional study.

OBJECTIVES: National immunisation coverage rate masks subnational immunisation coverage gaps at the state and local district levels. The objective of the current study was to determine the sociodemographic factors associated with incomplete immunisation in children at a sub-national level. DESIGN: Cross-sectional study using the WHO sampling method (2018 Reference Manual). SETTING: Fifty randomly selected clusters (wards) in four districts (two urban and two rural) in Enugu state, Nigeria. PARTICIPANTS: 1254 mothers of children aged 12-23 months in July 2020. PRIMARY AND SECONDARY OUTCOME MEASURES: Fully immunised children and not fully immunised children. RESULTS: Full immunisation coverage (FIC) rate in Enugu state was 78.9% (95% CI 76.5% to 81.1%). However, stark difference exists in FIC rate in urban versus rural districts. Only 55.5% of children in rural communities are fully immunised compared with 94.5% in urban communities. Significant factors associated with incomplete immunisation are: children of single mothers (aOR=5.74, 95% CI 1.45 to 22.76), children delivered without skilled birth attendant present (aOR=1.93, 95% CI 1.24 to 2.99), children of mothers who did not receive postnatal care (aOR=6.53, 95% CI 4.17 to 10.22), children of mothers with poor knowledge of routine immunisation (aOR=1.76, 95% CI 1.09 to 2.87), dwelling in rural district (aOR=7.49, 95% CI 4.84 to 11.59), low-income families (aOR=1.56, 95% CI 1.17 to 2.81) and living further than 30 min from the nearest vaccination facility (aOR=2.15, 95% CI 1.31 to 3.52). CONCLUSIONS: Although the proportion of fully immunised children in Enugu state is low, it is significantly lower in rural districts. Study findings suggest the need for innovative solutions to improve geographical accessibility and reinforce the importance of reporting vaccination coverage at local district level to identify districts for more targeted interventions.

Morbidities & outcomes of a neonatal intensive care unit in a complex humanitarian conflict setting, Hajjah Yemen: 2017-2018.

BACKGROUND: The protracted conflict in Yemen has taken a massive toll on the health system, negatively impacting the health of children, especially the most vulnerable age group; the newborns. METHODS: A 2-year retrospective study of admissions into the Neonatal Intensive Care Unit (NICU) in Al-Gomhoury Hospital Hajjah, Northwest Yemen was conducted. Data was analyzed with IBM SPSS® version 25.0 statistical software using descriptive/inferential statistics. RESULTS: A total of 976 newborns were eligible and included in this study; 506 preterm newborns (51.8%) and 470 term newborns (48.2%). Over half, 549 (56.3%) newborns were admitted within 24 h after birth and 681 (69.8%) newborns travelled for over 60 min to arrive at the NICU. The most common admission diagnoses were complications of prematurity (341; 34.9%), perinatal asphyxia (336; 34.4%), neonatal jaundice (187; 18.8%), and neonatal sepsis (157, 16.1%). The median length of stay in the NICU was 4 days. There were 213 neonatal deaths (Facility neonatal mortality rate was 218 neonatal deaths per 1000 livebirths); 192 (90.1%) were preterm newborns, while 177 (83.1%) were amongst newborns that travelled for more 60 min to reach the NICU. Significant predictors of neonatal deaths are preterm birth (aOR = 3.09, 95% CI: 1.26-7.59, p = 0.014 for moderate preterm neonates; aOR = 6.18, 95% CI: 2.12-18.01, p = 0.001 for very preterm neonates; and aOR = 44.59, 95% CI: 9.18-216.61, p <  0.001 for extreme preterm neonates); low birth weight (aOR = 3.67, 95% CI: 1.16-12.07, p = 0.032 for very low birth weight neonates; and aOR = 17.42, 95% CI: 2.97-102.08, p = 0.002 for extreme low birth weight neonates); and traveling for more than 60 min to arrive at the NICU (aOR = 2.32, 95% CI: 1.07-5.04, p = 0.033). Neonates delivered by Caesarean section had lower odds of death (aOR = 0.38, 95% CI 0.20-0.73, p = 0.004) than those delivered by vaginal birth. CONCLUSIONS: Preterm newborns bear disproportionate burden of neonatal morbidity and mortality in this setting which is aggravated by difficulties in accessing early neonatal care. Community-based model of providing basic obstetric and neonatal care could augment existing health system to improve neonatal survival in Yemen.

Association between time of delivery and poor perinatal outcomes -An evaluation of deliveries in a tertiary hospital, South-east Nigeria.

OBJECTIVES: Nigeria account for a significant proportion of adverse perinatal outcome. Nigerian studies assessing impact of time of delivery on perinatal outcome are scarce. This study evaluates any associations between time of delivery and perinatal outcome. METHODS: This was a cross-sectional study at the Federal Teaching Hospital, Abakaliki from 01 January 2016 to 30 June 2018. Data were analysed with IBM SPSS version 25.0. RESULTS: A total of 4,556 deliveries were analysed. Majority (72.2%) delivered on week days and 27.8% on weekends. Over 90% had 1st and 5th minutes Apgar scores ≥7. There was statistical difference in NICU admission between morning and evening hours (p = 0.009) but not between morning and night hours (p = 0.795). ENND during evening was twice higher (1.2%) than morning (0.5%); p = 0.047 and night hours (0.6%); p = 0.623.There was no difference in the risk of fresh stillbirths between morning and evening (p = 0.560), as well as morning and night hours (p = 0.75), there was also no difference in fresh stillbirths between week days and weekends (p = 0.895). There was no difference in low Apgar scores at 1st minute between morning and evening (p = 0.053) and night (p = 0.221), and between weekdays and weekends (p = 0.524). Similarly, there was no difference in low 5th minute Apgar scores between morning and evening (p = 0.165) and night (p = 0.944), as well as between week days and weekends (p = 0.529). However, ENND was twice (p = 0.085) and 1.3 times higher (p = 0.526) for evening and night hours respectively, while there was no difference between weekends and week days (p = 0.652). CONCLUSION: NICU admission and ENND were commoner during evening hours. However, work hours did not affect the rate of stillbirth and low Apgar scores during weekdays and weekends. It is pertinent for each obstetric unit to identify and modify factors responsible for unfavourable outcomes during various shifts, with the aim of improving perinatal health.

Risk factors for Clostridium difficile infections - an overview of the evidence base and challenges in data synthesis.

BACKGROUND: Recognition of a broad spectrum of disease and development of Clostridium difficile infection (CDI) and recurrent CDI (rCDI) in populations previously considered to be at low risk has renewed attention on differences in the risk profile of patients. In the absence of primary prevention for CDI and limited treatment options, it is important to achieve a deep understanding of the multiple factors that influence the risk of developing CDI and rCDI. METHODS: We conducted a review of systematic reviews and meta-analyses on risk factors for CDI and rCDI published between 1990 and October 2016. RESULTS: 22 systematic reviews assessing risk factors for CDI (n = 19) and rCDI (n = 6) were included. Meta-analyses were conducted in 17 of the systematic reviews. Over 40 risk factors have been associated with CDI and rCDI and can be classified into three categories: pharmacological risk factors, host-related risk factors, and clinical characteristics or interventions. Most systematic reviews and meta-analyses have focused on antibiotic use (n = 8 for CDI, 3 for rCDI), proton pump inhibitors (n = 8 for CDI, 4 for rCDI), and histamine 2 receptor antagonists (n = 4 for CDI) and chronic kidney disease (n = 4 for rCDI). However, other risk factors have been assessed. We discuss the state of the evidence, methods, and challenges for data synthesis. CONCLUSION: Several studies, synthesized in different systematic review, provide valuable insights into the role of different risk factors for CDI. Meta-analytic evidence of association has been reported for factors such as antibiotics, gastric acid suppressants, non-selective NSAID, and some co-morbidities. However, despite statistical significance, issues of high heterogeneity, bias and confounding remain to be addressed effectively to improve overall risk estimates. Large, prospective primary studies on risk factors for CDI with standardised case definitions and stratified analyses are required to develop more accurate and robust estimates of risk effects that can inform targeted-CDI clinical management procedures, prevention, and research.